Healthcare Provider Details

I. General information

NPI: 1558648709
Provider Name (Legal Business Name): KEWA PUEBLO HEALTH CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2011
Last Update Date: 11/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 W HIGHWAY 22
SANTO DOMINGO NM
87052-0340
US

IV. Provider business mailing address

PO BOX 559
SANTO DOMINGO PUEBLO NM
87052-0559
US

V. Phone/Fax

Practice location:
  • Phone: 505-465-3060
  • Fax: 505-465-1191
Mailing address:
  • Phone: 505-465-3060
  • Fax: 505-465-1191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: VANESSA DIANA VIGIL
Title or Position: BUSINESS OFFICE MANAGER
Credential:
Phone: 505-465-3060